Form DOT F 1120.1 DOT F 1120.1 Advisory Committee Candidate Biographical Information Re

APPENDIX 1

U.S. DEPARTMENT OF TRANSPORTATION

COMMITTEE BACKGROUND INVESTIGATION DISCLOSURE FORM

DISCLOSURE

As part of the process of determining your eligibility for a Department of Transportation (DOT) committee appointment and, in the event you are appointed your continued involvement with the committee, DOT may conduct an investigation of your background by obtaining a consumer report or investigative consumer report relating to you from a consumer reporting agency of its choice. The report may contain information bearing on your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, education, employment history, criminal history, motor vehicle history, workers compensation history or mode of living.

No consumer report will be used in violation of any federal or state equal employment opportunity law or regulation. I acknowledge receipt of a copy of my rights under the Fair Credit Reporting Act. If DOT intends to take any adverse action based in whole or in part on information contained in a consumer report, you will be provided with an additional copy of the report and a description of your rights under the Fair Credit Reporting Act.

Public Burden Statement

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2105-0009. Public reporting for this collection of information is estimated to be approximately 15 minutes per response, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All responses to this collection of information are voluntary. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, U.S. Department of Transportation, 1200 New Jersey Avenue, SE, Washington, D.C. 20590.

To assist DOT in obtaining a consumer report, the following information is provided:

MA, MN, OK, NY, ME, WA, NJ, and CA applicants only: If you want a free copy of the report(s) ordered, check this box .

Full Name (Printed) _______________________________________________________________________________________________________

First Middle Last Maiden/Other

Signature ______________________________________________________ Date ___________________________________

Complete Residence Address ______________________________________________________________________________________________________

Street Number/ PO Box Street Name

______________________________________________________________________________________________________

City State Zip Code County

Date of Birth* ______________________ Social Security Number* __________________ Gender____ Race______________

(*You may elect to call Mind Your Business Inc. directly at (888) 758-3776 with this information)

Driver’s License Number _______________________________________________ State Issued ________________________

Daytime Telephone Number _________________________________ Email _________________________________________

Please list all additional residences that you have resided in during the past 7 years:

________________________________________________________________________________________________________

Street Number/ PO Box Street Name City State Zip County

________________________________________________________________________________________________________

Street Number/ PO Box Street Name City State Zip County

________________________________________________________________________________________________________

Street Number/ PO Box Street Name City State Zip County

Are you a federally registered lobbyist?

_____________________________________________________________________________________________

Are you a federally registered foreign agent?

_____________________________________________________________________________________________

*This information is voluntary. However, without this information, we will be unable to properly identify you in the event we find adverse information during the course of our background search.

Privacy Act Statement (5 U.S.C. § 552a, as amended):  AUTHORITY: The Federal Advisory Committee Act, Pub. L. 92-463, as amended, authorizes DOT to collect this information.  PURPOSE(S):  DOT will use the information provided to evaluate and select individuals for membership on advisory committees within the jurisdiction of the Department.  ROUTINE USE(S):  In accordance with DOT’s system of records notice, Federal Advisory Committee Files, the information provided may be disclosed to other Federal agencies when necessary to administer DOT’s advisory committees, and to the public to inform the public of advisory committee membership and activities. DISCLOSURE:  Provision of the requested information is voluntary; however, failure to furnish the requested information may result in an inability of the Department to adequately evaluate an individual’s application for members on a DOT advisory committee.

APPENDIX 2

U.S. DEPARTMENT OF TRANSPORTATION

COMMITTEE BACKGROUND INVESTIGATION AUTHORIZATION FORM

AUTHORIZATION

I hereby authorize the Department of Transportation (DOT) to make an independent investigation of my background by obtaining a consumer report relating to me from Mind Your Business, Inc. (“MYB”). I understand and agree that the information contained in any consumer report will be used to determine eligibility for a Committee appointment and, if I am appointed, my eligibility for continued involvement, and that action may be taken by DOT based on this information.

I further authorize any person, business entity or governmental agency who may have information relevant to the above to disclose the same to ___________________, by and through MYB, including but not limited to, any courthouse, any public agency, any and all law enforcement agencies and any and all credit bureaus, regardless of whether such person, business entity or governmental agency compiled the information itself or received it from other sources, including alcohol and controlled substance information from previous employers.

Full Name (Printed) ____________________________________________________________________________________________________

First Middle Last Maiden/Other

Signature _______________________________________________ Date ________________________________________